If you are a veteran who has recently been discharged from active duty, you may be wondering what benefits you are eligible for. One benefit that may be available to you is the VA Form 10 0426. This form can help you obtain disability compensation from the Department of Veterans Affairs (VA). In this blog post, we will discuss what the VA Form 10 0426 is, and how to complete it. We will also provide tips on how to submit your application for disability compensation.
You'll discover details about the type of form you would like to prepare in the table. It will tell you how much time it will take to finish va form 10 0426, exactly what parts you will need to fill in and a few further specific details.
Question | Answer |
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Form Name | Va Form 10 0426 |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | va form 10 0426, veteran affairs form 10 0426, champva prescription claim form, va form 10 0426 printable |
Department of Veterans Affairs Meds by Mail Order Form
A mail order prescription service for qualified CHAMPVA and Spina Bifida beneficiaries
This form is for Prescription Orders Only
Important Information
●This form must be filled out completely including your Social Security number and Date of Birth for identification purposes. If you cannot be identified, your prescription will not be filled.
●Attach the original prescription to this form. Photocopies of prescriptions are not accepted.
●This order form is required EVERY TIME a written prescription from your medical provider is mailed.
●This form is to be completed by the patient, family member, or caregiver with power of attorney.
●Use a separate form for each patient or family member.
●Medication delivery may take up to 21 days from the date you mail your order. To ensure that you have enough medication to last until your shipment arrives, request a second written prescription for a
●This mail order service is provided only for maintenance medication―that is, medications that are required for extended periods of time. All
Patient Prescription Information
This form must be filled out completely - TYPE or PRINT information below:
Patient Name: (Last, First, Middle Initial)
Patient SSN
Date of Birth
Mailing Information (Type or Print where the prescriptions are to be mailed)
Patient Mailing Address:
Daytime Phone Number (Including Area Code):
Address 1 |
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Home: |
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Cell: |
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Address 2 |
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Today's Date: |
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Federal law requires that your medication be dispensed in a |
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container with a child resistant or safety cap. If you would like your |
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prescription with an |
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I request that these prescriptions and all refills of these |
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Is this a change of address? |
Yes |
No |
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prescriptions dispensed in |
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Is this a permanent change? |
Yes |
No |
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containers. |
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Is this a temporary change? |
Yes |
No |
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Signature: |
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Medication Allergies |
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Health Conditions |
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No known allergies |
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Arthritis |
Glaucoma |
Liver Disease |
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Aspirin |
NSAIDS |
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Asthma |
Heart Problem |
Seizures/Epilepsy |
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Cephalosporin |
Penicillin |
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COPD |
High Cholesterol |
T Thyroid |
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Codeine |
Sulfa |
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Depression |
Hypertension |
Ulcer/Acid Reflux |
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Erythromycin |
Tetracycline |
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Diabetes |
Kidney Disease |
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Other (specify) |
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Other (specify) |
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Food Allergy (specify) |
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VA |
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FORM |
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Page 1 of 2 |
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JAN |
2016 |
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VA FORM |
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Page 1 of 2 |
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DEC 2016 |
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Where to Mail your Prescriptions:
WEST |
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EAST |
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If you live in one of the following states or |
If you live in one of the following districts, states or |
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territories, mail your order form to the address |
territories, mail your order form to the address |
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listed below: |
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listed below: |
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Alaska, American Samoa, Arizona, Arkansas, |
Alabama, Connecticut, Delaware, Florida, |
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California, Colorado, Guam, Hawaii, Idaho, Illinois, |
Georgia, Kentucky, Maine, Maryland, |
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Indiana, Iowa, Kansas, Louisiana, Michigan, |
Massachusetts, Mississippi, New Hampshire, |
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Minnesota, Missouri, Montana, Nebraska, Nevada, |
New Jersey, New York, North Carolina, Ohio, |
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New Mexico, North Dakota, Northern Mariana |
Pennsylvania, Puerto Rico, Rhode Island, South |
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Islands, Oklahoma, Oregon, South Dakota, Texas, |
Carolina, Tennessee, Vermont, Virginia, Virgin |
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Utah, Washington, Wisconsin, Wyoming. |
Islands, Washington D.C., West Virginia. |
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Telephone: |
Telephone: |
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Address: |
Meds by Mail |
Address: |
Meds by Mail |
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PO Box 20330 |
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PO Box 9000 |
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Cheyenne, WY |
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Dublin, GA |
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How to Request Prescription REFILLS:
This form is for use when you send a paper prescription written by your medical provider. Refill orders should be placed by calling our automated refill system. Simply call
We now accept electronic prescriptions directly from your doctor. Ask your doctor if they can
Provider Information
Provider Name:
Provider Contact:
VA FORM |
Page 2 of 2 |
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DEC 2016 |